ORIGINAL ARTICLE ISSN 1598-3889 eissn 2234-0998 J Korean Soc Surg Hand 2011;16(2):57-63. JOURNAL OF THE KOREAN SOCIETY FOR SURGERY OF THE HAND AlloDerm 을이용한수부와족부의복합개방성창상의치료 Treatment of Complex Open Wounds Using AlloDerm in Hand and Foot 한형민 1 이동원 1 김석원 2 탁관철 1 연세대학교의과대학성형외과학교실인체조직복원연구소 1, 연세대학교원주의과대학성형외과학교실 2 접수일 2011 년 4 월 4 일수정일 2011 년 4 월 29 일게재확정일 2011 년 5 월 4 일교신저자탁관철서울특별시서대문구신촌동 134 연세대학교의과대학성형외과학교실 TEL 02-2228-2214 FAX 02-393-6947 E-mail kctark@yuhs.ac 본논문은제 27 차대한수부외과 2009 년학술대회구연발표되었음. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non- Commercial License (http://creativecommons.org/ licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 목적 : 인대나골이노출된수부, 족부의개방성창상에 AlloDerm 과함께피부를이식해서기능적, 미용적으로만족할만한재건결과를얻었기에보고하는바이다. 대상및방법 : 수부와족부의연부조직결손으로내원한환자들중건이나골, 골막등이노출되어있으나, 피판을사용할수없었던 11명의환자 ( 수부 7예, 족부 4예 ) 를대상으로 AlloDerm 과피부이식술을이용하여재건하였다. 평균추시기간은 30개월 ( 범위, 14-48개월 ) 이었다. 수술후이식조직의생착, 상처치유과정, 수지의운동범위회복을조사하였다. 결과 : AlloDerm 과이식피부는모든예에서생착이이루어졌다. 인지와중지의신전건이노출되었던 1예, 중지, 환지, 약지의신전건이노출되었던 1예등도합다섯개수지모두의굴곡, 신전기능은정상측과비교하여평균 89.2% 회복하였다. 족부의창상도불안정한반흔이나궤양없이성공적으로치료되었다. 결론 : 피판술이불가능하고인대나골이노출된수부, 족부의개방성창상에 AlloDerm 과피부를이식함으로써높은피부이식생착률을얻을수있고안정된창상재건과함께인대의유착을예방하여건활주운동을성공적으로회복할수있다. 색인단어 : 수부손상, 복합개방성창상, AlloDerm, 부분층피부이식 서론 수부나족부는인체의말단부에위치하기때문에기계적외상이나화상에쉽게노출된다. 더욱이수배부 (dorsum of hand) 는피부가얇아피부가결손되면인대가노출되기쉽다. 족부또한외상으로인대나골이쉽게노출되어이를재건하는여러가지방법들이연구되어왔다. 일반적으로혈액순환이풍부하지않은이러한하부구조들이노출되었을때는, 드레싱과항생제등의보존적치료로는이차적창상치유를기대하기힘들다. 또한반흔구축, 인대구축이동반될경우인대의활주운동이방해를받아운동장애가생길수있다. 이러한수부와족부의연부조직결손의재건은가장간단한일차봉합부터 복잡한유리피판술까지다양하게고려될수있다. AlloDerm (LifeCell Corp, Branchburg, NJ, USA) 은사체에서얻은피부를효소처리를통해표피를분리한후면역반응을유발하는항원성과모든진피세포를제거하여얻어진 acellular dermal matrix이다 1. 이는콜라겐기질 (collagen matrix), 탄력소 (elastin), 프로테오글라이칸 (proteoglycan) 과기저막복합체 (basement membrane complex) 로이루어져있으며, 연부조직결손, 구강점막질환, 비천공, 고막천공과복부결손등에사용되고있다. 2004년 Butler 와 Prieto 2 는복부수술에서 AlloDerm 은이식후변성되고반흔조직이적으면서도혈관이풍부한조직으로대체되어주위구조물과의예방적방벽을형성함으로써유착을방지하는것 Copyright c 2011. The Korean Society for Surgery of the Hand 57
J Korean Soc Surg Hand Vol. 16, No. 2, June 2011 으로보고하였다. 저자들은소아, 고령환자와피판술이어려웠던환자의수부와족부에생긴연부조직결손의재건을위해 AlloDerm 이식술과부분층피부이식술을동시에시행함으로써기능적, 미용적으로좋은결과를얻었기에문헌고찰과함께증례들의기능회복정도를보고하는바이다. 대상및방법 2006년 12 월부터 2009년 2월까지수부와족부의연부조직결손으로본원에내원한환자들중인대나골, 골막등이노출되어있으나피판술을시행하기어려웠던 11명의환자를대상으로 AlloDerm 과부분층자가피부이식술 (splitthickness skin graft) 을동시에시행하여재건하였다. 수부가 7예, 족부가 4예이었다. 모든환자에게서대부분의경우한차례수술 (one-stage operation) 로재건하였지만필요한경우, 재건수술전에변연절제술을일차적으로먼저하기도하였다. 재건수술은먼저변연절제술 (debridement) 과이물질제거 (foreign body removal) 시행후철저한지혈 (hemostasis) 을하였다. 이후창상에 AlloDerm (LifeCell Corp) 을덮고흡수성봉합사로고정하였다. 그위에외측대퇴부를공여부로하여피부채취기 (dermatome) 를이용하여부분층피부를얻었다. 피부이식편의두께는 10/1,000에서 18/ 1,000 inch 정도로 thin-tomedium 두께였다. 피부이식편의고정은비흡수성봉합사또는피부스태플러 (skin stapler) 를이용하였다. 체액의축적을예방하기위해피부이식편에띄엄띄엄절개창 (stab incision) 을만들고바닥봉합 (basting suture) 을가했다. 피부이식된창상은일반적인방법으로드레싱을시행하였다. 항생제가첨가된연고를바르고 petrolatum gauze를덮었다. 거즈를실로묶어고정하는 tie-over 드레싱과적절한압박드레싱 (compressive dressing) 을시행하였다. 수술후약일주일간그람양성균을커버하는주사항생제를사용하였고, 수술후 4-5일째드레싱을열어피부의생착상태를확인하였고바닥봉합을제거하였다. 상지에서는수술후 7-8일째, 하지에서는수술후 2주째에모든봉합사를제거하였다. 결과 술후 14-48개월 ( 평균 30 개월 ) 추적관찰을하였을때, 11 명의모든창상에서이식된피부는특별한문제없이생착되었다. 수술시간은평균 2시간 30분이었으며최장시간은 3시 Table 1. Demographic data of the patients Age Character of the Exposed deep Wound size Skin Op. F/U Case Sex (yr) Cause of injury wound Location structure (cm) thickness time (hr) Complication (mon) 1 F 10 TA, glass injury Infected open wound Rt dorsum of hand EDC of 2nd & 3rd 7x6 Thin 3 None 48 2 M 9 Escalator belt injury Infected open wound Lt dorsum of hand EDC of 3rd & 4th, 5th 6x6 Medium 2 Hypertrophic scar 26 3 M 45 Scalding burn Infected open wound Rt dorsum of hand, EDC (all), APL, EPL, 20x12 Thin 3 None 26 wrist extensor retinaculum 4 F 54 Flame burn Infected open wound Rt dorsum of hand APL. EPL 7x4 Thin 2 None 20 5 M 27 Flame burn Infected open wound Rt dorsum of hand EDC of 3rd & 4th, 5th 10x50 Medium 2.5 Hypertrophic scar 22 6 M 51 Flame burn Infected open wound Rt dorsum of hand EDC of 2nd & 3rd, 4th 4x4 Thin 1.5 None 17 7 F 70 Flame burn Infected open wound Rt dorsum of hand APL 5x4 Medium 2 Partial skin loss 17 8 M 12 TA, Bus run over 1st toe amputation Rt dorsum of foot, Great toe stump, 15x80 Thin 3 None 47 sole sole, foot dorsum 9 F 55 TA, Bus run over Ulcerative defect Lt posterior calf Tibia 4x3 Medium 1.5 Hypertrophic scar 25 10 F 55 TA, Bus run over Ulcerative defect Lt posterior calf Fascia 10x50 Medium 2 None 20 11 F 43 Necrosis due to Infected open wound Rt heel Calcaneus 7x8 Medium 2 Partial skin loss 14 herb injection Lt: left, Rt: right, Op: operation, F/U: follow-up, EDC: extensor digitorum communis, APL: abductor pollicis longus, EPL: extensor pollicis longus. 58
Hyung Min Hahn, et al. Treatment of Complex Open Wounds Using AlloDerm in Hand and Foot 간이었다 (Table 1). 세명의환자에서술후2개월경경미한비후성반흔 (hypertrophic scar) 이발생하였으나추적관찰에서반흔구축 (contracture) 이발생한예는없었다. 7명의환자에서신전건의손상이있었으며, 이중 2명의환자에서술후평균 30개월의추적관찰이가능하였다. 신전건이노출된수배부의개방성창상을갖고있던이들 2명의환자에서 AlloDerm 과자가피부이식을병행하여시행한후노출되었던다섯개의신전건의기능회복의정도를분석하였다. 이를위해손가락각관절의능동운동범위를측정하고이를합산하여 total range of active motion (TRAM) 의범위로삼고반대측정상수지의 TRAM (Table 2 3,4 ) 과의백분율로환산함으로써비교하였다. 평균 TRAM은해당정상수지의 89.2% 수준이었다 (Table 3). 1. 증례 1 10세여자환자로자동차를타고가던중차가전복되는사고로오른쪽손을유리창에부딪혀생긴손등의연부조직결손을주소로내원하였다. 내원당시두번째와세번째손가락의등쪽부위에피부전층과피하층을포함한연부조직결손이있었으며, 인지와중지의신전건이노출되어있었다. 입원후 7일간고식적치료로서육아조직의형성을유도하였다. 이 Tabl e 2. Normal range of motion 3,4 in each digit and their cumulative range of motion ( ) Joint Thumb ( ) Fingers ( ) DIP 70 PIP (IP for thumb) 80 100 Cumulative 80 170 MP 60 90 Cumulative 140 260 C-MC for thumb 45 Cumulative 185 DIP: distal interphalangeal, PIP: proximal interphalangeal, IP: interphalangeal, MP: metacarpophalageal, C-MC: carpometacarpal. 후 AlloDerm 이식술및부분층피부이식술을시행하였다. 수술후특별한합병증은병발하지않았다. 이식된피부는완전히생착되었고궤양이나불안정창상은발생하지않았다. 술후 48개월에측정한두번째와세번째손가락의평균 TRAM은정상수지의 86.5% 정도였다 (Fig.1). 2. 증례 2 9세남자환아로백화점에스컬레이터벨트에왼쪽손이말려들어가면서발생한손등의연부조직결손으로내원하였다. 환아는내원당시단순방사선촬영에서골절은없었으며연부조직은손등과셋째, 넷째, 다섯째손가락의등쪽부분에신전건이노출을포함한벗겨짐손상이있었다. 각신전건의운동장애는없었다. 수상후입원하여일주일간주사항생제치료를시행하고육아조직의형성을확인하였다. 이후괴사조직을제거한후세번째, 네번째, 다섯번째손가락신전건의노출을확인하였고, 변연절제술, AlloDerm 이식술, 부분층피부이식술을시행하였다. 수술시간은 2시간이었고, 수술후특별한합병증은병발하지않았다. 수술후 5일째첫드레싱을교환하였고이후 2일마다드레싱을교환하면서피부이식상태를확인하였다. 이식된피부의손실및감염은없었으며술후 8일째퇴원하였다. 술후 26 개월에측정한세번째, 네번째, 다섯번째손가락의평균 TRAM은정상수지의 91% 정도였다 (Fig. 2). 고찰 상지나하지말단부에외상이나화상또는종양제거후발생한연부조직결손은건이나골등심부구조의노출을동반하기쉽다. 이러한경우, 가장간단한방법인일차봉합을생각해볼수있겠지만, 대부분의경우불가능한경우가많다. 따라서유경피판 (pedicled flap) 혹은유리피판 (free flap) 을이용한재건이가장이상적이다. 임상적으로골수염이나건막 Table 3. Postoperative TRAM of 5 digits in 2 patients with compound dorsal hand injuries Case Name Sex Age Cause of injury Lt/ Exposured TRAM Normal % Mean of F/U Rt ( ) TRAM ( ) 3 Normal case (%) (mon) 1 Lee F 10 TA, glass injury Rt Index 230 260 88.5 86.5 48 Middle 220 260 84.6 2 Nam M 9 Escalator belt Lt Middle 240 260 92.3 91.0 26 Ring 240 260 92.3 Little 230 260 88.5 Mean 232 260 89.2 37.0 SD 8.4 3.2 TRAM: total range of active motion, Lt: left, Rt: right, F/U: follow-up, TA: traffic accident, SD: standard deviation. 59
J Korean Soc Surg Hand Vol. 16, No. 2, June 2011 Fi g. 1. Photographs of the hand in 10-year-old female who underwent AlloDerm graft and split thickness skin graft for wound reconstruction. Preoperative (A) and immediate postoperative (B), postoperative 4 months (C), and 48 months (D) photographs. Total range of motion of the index and middle fingers was 86.5% of the normal side. 염 (tenosynovitis) 이의심될때는혈액순환이풍부한피판을사용하는것이좋다. 하지만소아나노인, 전신상태가불안정한환자에서는피판술을적용하기힘들고, 장기간의입원과치료로인해많은시간이필요로하게된다. 또한피판이전술은피부이식술보다실패율이높고, 실패하면공여부의유병등그후유증이훨씬심각하다. 공여부에따라서는심각한조직결손혹은장해가발생할수도있다. 또한피판의특성상이전후필요이상의용적으로인해이차적수술이필요한경우가생길수있다. 따라서보다간단하고수월하게재건이가능하고환자의위험부담이적은여러방법들이연구되고있는데, 그중인공진피 (artificial dermis) 와피부이식을이용한재건방법이다. 일반적으로피부이식의생착은수혜부바닥으로부터자라올라오는혈관과의접합으로이루어지므로수혜부가건이나골혹은골막이노출되어혈액순환이좋지않은경우완전한생착을기대하기힘들다. 그러나최근 Chen 등 5 은골혹은골막이노출된하지의연부조직결손환자에서일차로인공진피 (artificial dermis) 를이식하고 2-4주후자가부분층피부이식을하여좋은결과를얻었다고보고하였다. 또한 2008년에 Jung 등 6 은두피에두개골이노출된연부조직손상환자에서두개골바깥층을제거후 AlloDerm 과부분층피부이식을이용해피복한증례를보고하였다. 2008년에 Wong 등 7 이쥐실험을통해 AlloDerm 이이식후약 3일경부터신생혈관생성을일으킨다고보고하였다. 기존의여러연구결과들을종합해볼때, AlloDerm 과자가부분층피부이식을병행할경우혈액순환이좋지않은연부조직결손부위를재건하는데있어기능적으로, 외형적으로비교적만족할만한결과를얻을것으로기대된다. 본연구에서는수부나하지에건, 골, 골막이노출된결손부위에 AlloDerm 과피부이식술을동시에시행하였고, 모든증례에서피판술못지않게좋은결과를얻을수있었다. 특히수부의복합손상인경우인대의유착없이활주운동 (gliding motion) 을회복하는것이재건의핵심인데, 본연구에서수술후평균 30 개월추적관찰했을때반대편손과비교하여평균 60
Hyung Min Hahn, et al. Treatment of Complex Open Wounds Using AlloDerm in Hand and Foot Fi g. 2. Photographs of the hand in 9-year-old male who underwent AlloDerm graft and split thickness skin graft to cover and exposed 3 rd,4 th,5 th extensors on the dorsum of left hand following avulsion injury by escalator belt (A-C). Twenty six months after operation, total range of motion of the 3 rd,4 th,5 th, fingers was 91% in average of the normal side (D-F). 89.2% 의능동운동범위를회복하는것을확인할수있었다. 이는 2007년 Choi 등 8 이토끼실험에서파열된굴곡건의일차봉합부위에 AlloDerm 을감싸건주위유착 (peritendinous adhesion) 이방지됨을확인한결과와일치한다. 또한요골전완피판 (radial forearm flap) 의공여부를 AlloDerm 을이용해피복한경우에도건의유착을예방할수있다고보고하였다 9. AlloDerm 이여러연구에서유착을방지한다고알려져있지만자세한기전은아직밝혀지지않았다. 아마도창상의안정화와관련이있을것으로생각된다. 최근 Yim 등 10 이보고한연구에서 AlloDerm 을이용해재건한화상창상에서 trans-epidermal water loss가더안정적이라는결과를얻었다. 본연구에서는건이노출된수부와골이노출된하지의연부조직결손이있으면서피판술을사용할수없는경우에서 AlloDerm 과자가부분층피부이식술을동시에시행함으로써기능적으로, 외형적으로만족할만한결과를얻을수있었다. 결론 저자들은건이나골이노출된수부, 족부의개방성창상에 AlloDerm 과자가피부를동시에이식하여치료하였다. 이는기술적으로비교적쉬울뿐아니라수술시간도기존의피판술보다훨씬단축시킬수있다. 또한안정적인피부이식생착률을기대할수있고안정된창상재건과함께인대의유착없이활주운동능력을회복하여만족할만한치료결과를얻을수있다. 참고문헌 1. Butler CE, Langstein HN, Kronowitz SJ. Pelvic, abdominal, and chest wall reconstruction with AlloDerm in patients at increased risk for mesh-related complications. Plast Reconstr Surg. 2005;116:1263-75. 2. Butler CE, Prieto VG. Reduction of adhesions with composite AlloDerm/polypropylene mesh implants for abdominal wall reconstruction. Plast Reconstr Surg. 2004;114:464-73. 3. Rondinelli RD. Clinical measurement of motion in upper extremity. In: American Medical Association, editor. Guides to the evaluation of permanent impairment. 6th ed. Chicago: American Medical Association; 61
J Korean Soc Surg Hand Vol. 16, No. 2, June 2011 2008. p459-78. 4. Tark KC, Kim YW, Lee YH, Lew JD. Replantation and revascularization of hands: clinical analysis and functional results of 261 cases. J Hand Surg Am. 1989;14:17-27. 5. Chen X, Chen H, Zhang G. Management of wounds with exposed bone structures using an artificial dermis and skin grafting technique. J Plast Reconstr Aesthet Surg. 2010;63:e512-8. 6. Jung SN, Chung JW, Yim YM, Kwon H. One-stage skin grafting of the exposed skull with acellular human dermis (AlloDerm). J Craniofac Surg. 2008;19:1660-2. 7. Wong AK, Schonmeyr B, Singh P, Carlson DL, Li S, Mehrara BJ. Histologic analysis of angiogenesis and lymphangiogenesis in acellular human dermis. Plast Reconstr Surg. 2008;121:1144-52. 8. Choi CY, Song JW, Kim JH, Choi HJ, Lee YM. The effect of alloderm on prevention of adhesions following tenorrhaphy in the rabbits. J Korean Soc Plast Reconstr Surg. 2007;34:765-70. 9. Rowe NM, Morris L, Delacure MD. Acellular dermal composite allografts for reconstruction of the radial forearm donor site. Ann Plast Surg. 2006;57:305-11. 10. Yim H, Cho YS, Seo CH, Lee BC, Ko JH, Kim D et al. The use of AlloDerm on major burn patients: AlloDerm prevents post-burn joint contracture. Burns. 2010;36:322-8. 62
Hyung Min Hahn, et al. Treatment of Complex Open Wounds Using AlloDerm in Hand and Foot Treatment of Complex Open Wounds Using AlloDerm in Hand and Foot Hyung Min Hahn, MD 1, Dong Won Lee, MD 1 Sug Won Kim, MD, PhD 2, Kwan Chul Tark, MD, PhD, FACS 1 1 Institute for Human Tissue Restoration, Department of Plastic and Reconstructive Surgery, Yonsei University College of Medicine, Seoul, Korea 2 Department of Plastic and Reconstructive Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea Purpose: The purpose of this study is to evaluate the functional and aesthetic outcomes of the reconstruction of complicated open wounds with exposure of the bone, periosteum, or tendon using AlloDerm and skin graft in hand and foot. Materials and Methods: Seven cases of hand and 4 cases of foot were treated with combined AlloDerm graft and split thickness skin graft in a single stage for managing the soft tissue defect of extremities where bone, periosteum, or tendon were exposed but flap operation was not feasible. The mean postoperative follow-up period was 30 months (range: 14-48 month). Postoperatively, we assessed graft taking rate, wound healing process, and the recovery of motion of hand and foot. Results: AlloDerm and skin graft were readily assimilated into the wound in all cases. The mean postoperative range of motions of the 5 fingers with exposed digital tendons were 89.2% of the normal side. Reconstructions of wound in the foot were successfully settled without unstable scar or ulcer in all cases. Conclusion: Composite grafting with AlloDerm and autologous skin graft for reconstruction of complex open wound in hand and foot where deep structures are exposed provides stable reconstruction of the wound with high taking rate, successful recovery of tendon gliding motion by preventing adhesion. Keywords: Hand injury, Complex open wound, AlloDerm, Split-thickness skin graft Received: April 4, 2011 Revised: April 29, 2011 Accepted: May 4, 2011 Correspondence to: Kwan Chul Tark, MD, PhD, FACS Department of Plastic & Reconstructive Surgery, Yonsei University College of Medicine, 134 Sinchon-dong, Seodaemun-gu, Seoul 120-752, Korea TEL: +82-2-2228-2214 FAX: +82-2-393-6947 E-mail: kctark@yuhs.ac 63